Yves Van Belle

Hysteroscopic follow-up during Tamoxifen treatment

In order to study the action of Tamoxifen upon the uterus, 16 breast cancer patients were prospectively evaluated by means of an hysteroscopy before Tamoxifen therapy and again after 6 to 36 months of treatment. The results show the occurrence of an endometrial polyp in four cases and of an adenocarcinoma in one case. Moreover, the previously atrophic mucosa became mildly proliferative in seven of the patients who were evaluated.

Hysteroscopic findings in patients with a cervical polyp

OBJECTIVE Our objective was to determine the presence of intrauterine lesions in patients with a cervical polyp. STUDY DESIGN We performed a retrospective analysis to determine the influence of hormonal treatment and age on 165 patients with a cervical polyp and bleeding on admission. All 165 patients underwent a diagnostic hysteroscopy to rule out intrauterine lesions, including polyps, fibroids, hyperplasia, and adenocarcinoma. RESULTS Endometrial polyps were found in up to 26.7% of patients who had a cervical polyp. In patients undergoing a combined pill treatment this incidence was much lower (8.3%). Menopausal patients had a 56.8% incidence of cervix-related endometrial polyps, and hormone replacement therapy did not significantly increase (45.7% vs 28.6%) the incidence of coexisting polyps. All cervical polyps present during tamoxifen treatment were associated with endometrial polyps. Abnormal vaginal bleeding was of no clinical significance in excluding concomitant endometrial polyps. CONCLUSIONS All menopausal patients with a cervical polyp could benefit from a diagnostic hysteroscopy. Premenopausal patients receiving a combined pill treatment are the least likely to have coexistent endometrial polyps.

A valid model for testing and training laparoscopic psychomotor skills

This study aims to evaluate the face and construct validity of the Laparoscopic Skills Testing and Training (LASTT) model, developed by the European Academy of Gynaecological Surgery (EAGS) for assessing laparoscopic psychomotor skills (LPS). This study is designed based on the Canadian Task Force II-1. This study was conducted in workshops organised by the EAGS in 2008 and 2009. One hundred ninety-nine gynaecologists were classified in three groups according to their exposure to laparoscopy (G1: no/little, G2: intermediate, G3: important). Participants performed three repetitions of three exercises (E1: camera navigation, E2: hands–eyes coordination, E3: bimanual coordination) with measurable objectives to accomplish within a limited time frame. The face validity of the model was assessed by an 11-item questionnaire using a 10-cm visual analogue scale. Q1–Q8 evaluated its capacity for testing and training LPS and Q9–Q11 its relevance for actual laparoscopic surgery. The score of each exercise was obtained by dividing the time to correct performed exercise by the number of objectives effectively accomplished. The correlation between E1–E3 scores and the level of exposure to laparoscopy was evaluated, and the scores of the different groups were compared to assess the construct validity. Participants gave a favourable opinion about the model without inter-group differences. In E1–E3, the scores correlated with the level of previous exposure to laparoscopic procedures, more-experienced participants achieving better results than less-experienced participants. The data demonstrate the face and construct validity of the LASTT model, suggesting that it can be a useful tool for training and evaluation of LPS in surgical disciplines that perform laparoscopic procedures.

Gynaecological endoscopic surgical education and assessment. A diploma programme in gynaecological endoscopic surgery

In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologist who perform endoscopic surgery without proper training of the specific psychomotor skills, are at higher risk to increased patient morbidity and mortality. Although the apprentice-tutor model has long been a successful approach for training of surgeons, recently, clinicians have recognised that endoscopic surgery requires an important training phase outside the operating theatre. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) recognises the necessity of this structured approach and implements two separated stages in its learning strategy. In the first stage, a skill certificate on theoretical knowledge and specific practical psychomotor skills is acquired through a high-stake exam; in the second stage, a clinical programme is completed to achieve surgical competence and receive the corresponding diploma. Three diplomas can be awarded: (a) the Bachelor in Endoscopy, (b) the Minimally Invasive Gynaecological Surgeon (MIGS) and (c) the Master level. The Master level is sub-divided into two separate diplomas: the Master in Laparoscopic Pelvic Surgery and the Master in Hysteroscopy. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control. This programme is based on the best available scientific evidence, and it counteracts the problem of the traditional surgical apprentice-tutor model. It is seen as a major step toward standardisation of endoscopic surgical training in general.

Gynaecological Endoscopic Surgical Education and Assessment. A diploma programme in gynaecological endoscopic surgery

In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologist who perform endoscopic surgery without proper training of the specific psychomotor skills are at higher risk to increased patient morbidity and mortality. Although the apprentice-tutor model has long been a successful approach for training of surgeons, recently, clinicians have recognised that endoscopic surgery requires an important training phase outside the operating theatre. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA), recognises the necessity of this structured approach and implements two separated stages in its learning strategy. In the first stage, a skill certificate on theoretical knowledge and specific practical psychomotor skills is acquired through a high stake exam; in the second stage, a clinical programme is completed to achieve surgical competence and receive the corresponding diploma. Three diplomas can be awarded: (a) the Bachelor in Endoscopy; (b) the Minimally Invasive Gynaecological Surgeon (MIGS); and (c) the Master level. The Master level is sub-divided into two separate diplomas: the Master in Laparoscopic Pelvic Surgery and the Master in Hysteroscopy. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control. This programme is based on the best available scientific evidence and it counteracts the problem of the traditional surgical apprentice tutor model. It is seen as a major step toward standardization of endoscopic surgical training in general.

Tubal ostium membranes and their relation to infertility

OBJECTIVE To define the clinical significance of tubal ostium membranes. DESIGN Retrospective multivariate stepwise logistic regression analysis. SETTING Algemene Kliniek Sint--Jan, Brussels, Belgium. PATIENTS Three thousand forty-six hysteroscopies on 2979 patients, including 172 with infertility, over a 9-year period. MAIN OUTCOME MEASURES Presence of tubal ostium membranes, age, infertility, endometrial thickness, and hormonal environment. RESULTS Tubal ostial membranes were present in 74 (2.5%) patients: they were unilateral in 30 (42.1%) and bilateral in 44 (57.9%). Their presence was independent from hormonal state and from endometrial thickness. The incidence of ostial membranes was significantly higher (9.9%) in patients referred for infertility for unilateral (3.5%) as well as for bilateral presence (6.4%). Only the bilateral form was age dependent. CONCLUSIONS Tubal ostium membranes may be one of the unknown limiting factors affecting female fertility and thus reducing the monthly fecundity rate. The present data suggest that bilateral and unilateral tubal ostium membranes may have a different clinical significance. The unilateral form is unrelated to age, hormonal state, or endometrial thickness and can be congenital. This form is most clearly related to infertility. The bilateral form is less related to infertility, is found in women of older age, and can be acquired. Further prospective analysis is needed to clarify the pathogenesis and pathophysiology of tubal ostium membranes. Tubal ostium membranes should routinely be looked for when performing a hysteroscopic examination in infertile women.

Role of Hysteroscopy

Abnormal uterine bleeding in general, and menorrhagia in particular, is one of the most frequent reasons for patients to consult their gynaecologist.1 The knowledge that the objective measurement of menstrual bleeding will be less than 80 ml per period (the definition of menorrhagia) in more than half of cases does not release the gynaecologist from a standardised diagnostic management.2 This is important to avoid under- treatment, such as reassurance without correct diagnosis, as well as overtreatment, which would be a hysterectomy in the absence of organic uterine pathology. Important features deciding on the clinical value of a diagnostic procedure are simplicity, safety, patient compliance, cost-benefit relationship and accuracy.